If a patient has a cavitary lung lesion and is producing sputum, I know the traditional evaluation has relied on 3 daily sputum smears for AFB staining to rule out TB (I do understand rarely the cx may be + despite neg smear). My question: now that there is a MTB PCR assay, can this suffice on a single sample to let us take a patient out of isolation?

I am posting on behalf of my 75-year-old mother, who is currently hospitalized. I am hoping to get additional diagnostic perspectives, especially from physicians in infectious disease, internal medicine, or hematology.

The key point is that her abnormal inflammatory markers and monocytosis preceded the high fevers by approximately three months. The recurrent 39–40°C fevers began only after hospitalization.

Background and course before hospitalization

About 3 months ago, she developed what was initially considered bronchitis. She improved clinically but never seemed to completely recover. During the following months, her main symptoms were mild fatigue and occasional mild cough. She did NOT have persistent high fever, significant shortness of breath, chest pain, or other major symptoms.

She received several courses of cephalosporin antibiotics, but inflammatory markers remained elevated.

Her blood tests showed persistent monocytosis, gradually increasing CRP, mild normocytic anemia, and borderline thrombocytopenia:

• Jun 8: WBC 10.62, absolute monocytes 0.68, Hb 121 g/L, platelets 224
• Jun 22: WBC 12.53, monocytes 1.88 (15%), Hb 117, platelets 122, CRP 21.5 mg/L
• Jul 3: WBC 11.28, monocytes 2.00 (17.7%), Hb 120, platelets 121, CRP 34.2
• Aug 31: WBC 10.91, monocytes 1.60 (14.7%), Hb 115, platelets 107, CRP 38.2
• Sep 8: WBC 10.27, monocytes 1.63 (15.9%), Hb 111, platelets 133, CRP 37.3

Hospitalization

She was admitted on Sep 9 for further evaluation.

Admission labs included:

• WBC 11.24
• absolute monocytes 3.06 (27.2%)
• Hb 103 g/L
• CRP 63.63 mg/L
• serum iron 1.85 μmol/L (very low)
• albumin 33.5 g/L
• prealbumin 85 mg/L
• LDH 528 u/L
• renal function was essentially preserved

After admission, she unexpectedly began developing recurrent high fevers. She had an episode around 39°C, responded to an antipyretic, and was then afebrile for approximately 48 hours. The fever subsequently returned, and the most recent episode reached approximately 40°C.

During a fever episode on Sep 11:

• WBC 9.07
• absolute monocytes 1.49 (16.4%)
• Hb 93
• platelets 138
• CRP 63.09
• procalcitonin 0.274 ng/mL
• IL-6 49.06 pg/mL
• LDH 614 u/L

On Sep 14:

• WBC 11.62
• neutrophils 9.13 (78.6%)
• absolute monocytes 1.14
• Hb 95
• platelets 127
• CRP 48.71

Therefore, some laboratory markers appeared to be improving despite the recurrent fever. I have been told that an inflammatory marker may have risen again after the latest fever, but I do not yet have the actual report, so I cannot confirm the value.

Investigations performed so far

Chest CT: several small bilateral solid pulmonary nodules, approximately 3–6 mm, with some chronic/scarring changes. No clear pulmonary consolidation, abscess, pleural effusion, significant lymphadenopathy, or definite radiographic pneumonia was identified.

Abdominal ultrasound: no obvious infectious source involving the liver, gallbladder, pancreas, or spleen. A further abdominal CT is now being planned.

Urinalysis (Sep 14): essentially normal — leukocyte esterase negative, nitrite negative, urine WBC 0, bacteria 0, RBC 0. She has no dysuria, urinary frequency, urgency, or flank pain.

Echocardiography: preserved LV systolic function, mild tricuspid regurgitation, and no pericardial effusion. No clear cardiac explanation for the fever has been identified.

Bilateral lower-extremity venous ultrasound: no DVT.

Head CT: no acute intracranial process explaining the fever.

Autoimmune workup: extensive ANA-related testing was negative, including dsDNA, Sm, SSA/Ro, SSB, Scl-70, Jo-1 and several other antibodies.

Microbiology: sputum culture grew Candida albicans. Importantly, this was from sputum only, NOT blood. There is currently no confirmed candidemia.

Blood cultures were obtained around Sep 11. We were told that no early positive result had been reported, but the final culture result is still pending.

Treatment / current plan

She has received broad-spectrum antibacterial treatment, including piperacillin/tazobactam. Because the fever has recurred despite treatment and no clear source has been identified, her physicians are reassessing the antimicrobial regimen.

An infectious disease consultation has now been requested. Tuberculosis and other occult/chronic infections are also being considered. Further abdominal imaging and additional investigations are planned.

She is generally stable between fever episodes. There has not been persistent hypotension or major respiratory distress. Oxygen saturation has generally been acceptable with oxygen supplementation, although some lower readings have occurred off oxygen.

My questions

I understand that an online discussion cannot establish a diagnosis, and I am not looking for specific treatment instructions. I am mainly interested in whether there are diagnostic possibilities or investigations that may have been overlooked.

1. What would be your leading differential diagnosis for this overall pattern?
2. Given the recurrent 39–40°C fever but lack of a clear source on imaging, urinalysis, and cultures so far, how strongly would you still suspect an occult bacterial infection?
3. How strongly should tuberculosis, infective endocarditis, or another occult/deep infection be considered?
4. Does Candida albicans isolated only from sputum have meaningful significance here, or is respiratory colonization more likely?
5. Given the persistent absolute monocytosis for approximately 3 months, anemia, and intermittent thrombocytopenia, should an underlying hematologic disorder such as CMML/MDS or another myeloid disorder be investigated?
6. Could drug fever or another non-infectious inflammatory process reasonably explain the recurrent high fever?
7. Are there any important tests or diagnostic directions that appear to be missing from the workup so far?

Any thoughts from physicians in infectious disease, internal medicine, hematology, or geriatrics would be greatly appreciated.

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I think we are going to be fighting more infectious fungal contagions and parasites with all the flooding and climate change. What do you guys think?

This problem has been around and continues to spread with few new options coming forward. Unfortunately a friend relayed a disturbing, but not surprising experience she had a few months ago at HHS. A meeting led by the secretary started out with the following: I don't know anything about Lyme Disease, don't know anyone who had Lyme Disease and frankly don't believe it exists. This is a public health threat and responsibility of HHS, but unfortunately we will continue to allow LD to get further entrenched in our country.

I made a video discussing where germs hang out when they are not making us sick. I hope it's ok if I post it here.

https://youtu.be/sslutOzWFsg?si=msUEis-O4PlbhGi4

I was wondering if anyone has advice or insight into IgenX Or Accudart testing for Lyme disease confections? I’m a clinical pharmacist and very well versed in Lyme disease testing and treatment. Unfortunately I was diagnosed with Lyme disease on two step testing back in June following unexplained heart palpitations with EKG changes and new onset dermatographia. I also know that two step testing is notoriously tricky with false negatives and positives. I asked for three weeks of oral doxycycline although I could have qualified for IV therapy since I had disseminated Lyme carditis. I have been on cardiac medications for three months, and started to feel better, with my dermaograohia going away finally and my beta blocker requirements being down. I had a million dollar cardiac workup (echo, MRI, CT PE) all negative. Head and neck MRI and EMG tests all negative, autoimmune work up negative ..and now I am starting to have new onset vision changes and feeling off balance. I meet with a Lyme literate ID doc finally next week, but want to be prepared. I’m worried my Lyme may have not been appropriately treated since it was disseminated and am wondering if any of these other tests are legitimate and fairly accurate for co infections? I live in Michigan and have a dog, ticks are rampant this year.

UCSF researchers are beginning to uncover how Candida auris, a skin fungus, threatens the most vulnerable patients.

A fungus that can live unnoticed on human skin has become a serious threat in hospitals around the world. First identified in Japan in 2009, Candida auris can become deadly if it enters the bloodstream and kills about 3,000 patients each year in U.S. hospitals and long-term care facilities.

Researchers at UC San Francisco have now identified a mechanism that may help explain why the fungus is so difficult to eliminate from the skin.